About Medicare
The federal Medicare program is an essential pillar of the state’s health care system, supporting more than 6 million Californians over the age of 65 and younger Californians with disabilities. One in five hospitals is at risk of closing, in part because Medicare reimbursement rates are far lower than the cost of providing care. It’s essential that future federal Medicare policy protects patient care.
California’s Hospitals, Doctors Seek Congressional Delegation Support in Preserving Access to Care
What’s happening: In a joint letter to the California congressional delegation, CHA and the California Medical Association (CMA) asked members to support access to health care for all Californians in year-end legislation.
What else to know: Critical federal health care legislation on Medicaid, Medicare, and telehealth will be up for votes in December.
Senate Subcommittee Issues Scathing Report on Medicare Advantage Plans
What’s happening: The U.S. Senate Permanent Subcommittee on Investigations (PSI) released a report revealing that the three largest Medicare Advantage (MA) plans intentionally target costly stays in post-acute care facilities to increase profits.
What else to know: These MA plans denied prior authorization (PA) requests for post-acute care requests at far higher rates than they did for other types of care, resulting in diminished access to post-acute care for MA beneficiaries and an increase in the number of post-acute care services subject to PA. The PSI’s investigation also provided insight into automation and predictive technologies in the PA process.
Noridian Shares Resource for Outpatient Therapy Providers
What’s happening: Noridian, the Medicare administrative contractor (MAC) for California, has provided a one-page resource for outpatient therapy service providers, including physical therapy, occupational therapy, and speech/language pathology services.
What else to know: The resource includes information on coding and claim processing, therapy accruals, certification for therapy plan of care, advance beneficiary notice of noncoverage and more.
CMS Issues Final Rule on Appeals of Observation Status
What’s happening: The Centers for Medicare & Medicaid Services (CMS) has issued a final rule that establishes an appeals process for Medicare enrollees who are initially admitted as hospital inpatients but are subsequently reclassified as outpatient observation patients.
What else to know: The new regulations create processes for both retrospective appeals and prospective appeals. CMS expects the retrospective appeals to become operational in January 2025 and the prospective appeals to become operational in mid-February 2025.
CMS Finalizes Medicare Observation Appeals Processes
What’s happening: The Centers for Medicare & Medicaid Services (CMS) has established appeals processes for Medicare beneficiaries who were admitted as inpatient but whose status changed to outpatient observation during their hospital stay.
What else to know: The appeals processes only apply to patients enrolled in traditional Medicare, not patients enrolled in Medicare Advantage.
California Representatives Advocate for Access to IRF Care
What’s happening: Several California representatives joined fellow members of Congress in urging the Centers for Medicare & Medicaid Services (CMS) to take steps that will ensure Medicare Advantage (MA) plan beneficiaries have access to medically necessary inpatient rehabilitation facility (IRF) care.
What else to know: In the letter, the authors observe that, by statute, MA must cover all services included under traditional Medicare, including inpatient rehabilitation — an essential service for many beneficiaries when recovering from a major medical event.
Correction Notices Issued for Medicare Payment Final Rules
What’s happening: The Centers for Medicare & Medicaid Services issued correction notices to the federal fiscal year (FFY) 2025 Medicare payment final rules.
What else to know: The changes are minor, and the inpatient prospective payment system (IPPS) final rule changes are not reflective of the low-wage index interim final rule.
CMS Issues Updated Medicare Advantage Complaint Form
What’s happening: As previously reported, the Centers for Medicare & Medicaid Services (CMS) has developed a process that allows providers to submit questions and complaints related to Medicare Advantage (MA) plan appeals or claims payment issues.
What else to know: The form serves as a mechanism for Medicare providers seeking CMS assistance to resolve specific MA claims issues; CMS will enter complete complaint forms into the complaints tracking module and direct the MA to investigate the case.
CMS Issues Annual Data Submission Requirements for MA Plans
What’s happening: The Centers for Medicare & Medicaid Services (CMS) has issued detailed information about data collection and audit procedures for Medicare Advantage (MA) (Part C) plans.
What else to know: The information will allow CMS to conduct a comprehensive review of plan compliance with utilization management requirements, including new requirements on development, appropriateness, and public accessibility of internal coverage criteria.
CMS Discontinues Low-Wage Index Policy for FFY 2025
What’s happening: The Centers for Medicare & Medicaid Services (CMS) has eliminated its low-wage index hospital policy for federal fiscal year (FFY) 2025.
What else to know: CHA has supported a legal challenge to this policy on behalf of member hospitals since FFY 2020.